HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
Y-5-023
Topic:
Vision Therapy (Orthoptics and Pleoptics)
Section:
Therapy
Effective Date:
August 23, 2021
Issued Date:
August 23, 2021
Last Revision Date:
July 2021
Annual Review:
July 2021
 
 

Orthoptics and pleoptics are common forms of vision therapy. Orthoptics are exercises designed to improve accommodation (focusing) and binocular vision (eye muscle coordination). Orthoptics may be considered particularly useful in the treatment of strabismus (crossed or wandering eyes). Pleoptics are exercises designed to treat amblyopia, particularly in association with eccentric fixation. 

Policy Position

Othoptics and pleoptics may be considered medically necessary for ANY of the following (not an all-inclusive list):

  • Amblyopia; or
  • Strabismus; or
  • Accommodative dysfunction; or
  • General binocular dysfunction.

A maximum of two (2) exercise sessions per week for one (1) treatment period of six (6) consecutive months (based on a seven (7)-day week beginning with the first treatment session may be considered medically necessary as prescribed by an optometrist or ophthalmologist and performed by an optometrist, vision therapist or an occupational therapist.

The following methods of therapy are considered not medically necessary:

  • Vision therapy for the treatment of learning disabilities, poor school test scores, and behavioral problems; and
  • Vision therapy performed to maintain a level of function; and
  • Home computer orthoptic programs as there are no direct professional services rendered with home use.

Documentation will be required to substantiate medical necessity for further treatments beyond initial six months.

Vision therapy not meeting the criteria as indicated in this policy is considered not medically necessary and therefore non-covered.

92065

 

 

 

 

 

 


Covered Diagnosis Codes for Procedure Code 92065

H49.00

H49.01

H49.02

H49.03

H49.10

H49.11

H49.12

H49.13

H49.20

H49.21

H49.22

H49.23

H49.881

H49.882

H49.883

H49.889

H49.9

H50.00

H50.10

H50.21

H50.22

H50.30

H50.40

H50.50

H50.51

H50.52

H50.53

H50.60

H50.611

H50.612

H50.69

H50.89

H50.9

H51.11

H51.9

H52.531

H52.532

H52.533

H52.539

H53.001

H53.002

H53.003

H53.009

H53.011

H53.012

H53.013

H53.019

H53.021

H53.022

H53.023

H53.029

H53.031

H53.032

H53.033

H53.039

H53.32

H53.33

H55.82

 

 

 

 

 


Place of Service: Outpatient

Vision Therapy (Orthoptics and Pleoptics) is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.


Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.